Seacrest Post-Acute: IV Safety & Medication Errors - CA
The February incident at Seacrest Post-Acute Care Center revealed broader problems with basic medical care that federal inspectors documented during their visit. Staff left IV catheters in residents for weeks after treatment ended, administered medications incorrectly, and failed to provide proper denture care.
Resident 20 kept an IV catheter in her right wrist for weeks after her therapy concluded on February 5. When inspectors arrived February 26, the catheter was still there. The Registered Nurse Supervisor acknowledged it should have been removed immediately after treatment ended, noting that IV sites create potential sources for infection.
"IV catheters must be removed after the course of therapy was completed," the Director of Nursing told inspectors. "It could lead to infection and complications because there is an opening in the skin."
Another resident faced different IV problems. Resident 318 had an IV catheter placed at a general acute care hospital on February 14 for antibiotic treatment of bone infection in his left ankle and foot. The facility's own care plan required rotating IV sites every 72 hours, but the catheter remained in the same location for 12 days when inspectors found it February 26.
The IV site was wrapped with gauze dressing that had no date or time label. When the Registered Nurse Supervisor unwrapped the site during the inspection, she found the original hospital date showing it had been in place far longer than policy allowed.
"IV sites are a potential source for infection," the supervisor told inspectors. She acknowledged the site should have been rotated every 72 hours or monitored and documented daily for signs of infection, infiltration, or other complications.
The blood pressure incident involved Resident 368, who required multiple medications for hypertension and kidney failure. Licensed Vocational Nurse 4 needed to check the resident's blood pressure before administering hydralazine, a medication that must be held if systolic pressure drops below 100.
But LVN 4 placed the blood pressure cuff on Resident 368's right forearm near the wrist instead of the upper arm. She couldn't locate the reading on the monitor and asked the Director of Staff Development for help. They couldn't find the reading either.
When they returned to recheck, the Director of Staff Development corrected LVN 4's technique, placing the cuff on the upper arm. The reading was 147/78. LVN 4 prepared to administer the medication.
Then the Director of Staff Development realized another error. Resident 368 had a dialysis catheter on her upper right side, meaning blood pressure should have been taken on the opposite arm to avoid damaging the port. They rechecked on the left arm: 113/65.
Resident 368 refused the medication, saying her doctor told her to take hydralazine only if her blood pressure exceeded 160. LVN 4 explained the physician's order specified holding the medication only if systolic pressure fell below 100, but the resident continued refusing.
LVN 4 told inspectors her training came from a registry agency, not the facility. She hadn't worked at Seacrest in a long time. When asked about the incorrect blood pressure technique, she said she avoided the upper right arm because the resident had surgery on that side toward the chest area.
The Director of Staff Development said taking blood pressure on the arm with edema and a dialysis port increased risks for inaccurate readings, blocked circulation, additional pain, bruising, swelling, medication errors, and hospitalization.
Medication errors extended beyond blood pressure checks. Licensed Vocational Nurse 3 administered five medications to Resident 37, including an 81mg aspirin tablet specifically ordered as "chewable" for stroke prevention. The nurse failed to separate the chewable aspirin from other medications or instruct the resident to chew it. Resident 37 swallowed all medications together.
"The absorption of chewable aspirin would be affected and might not provide benefit to prevent stroke for Resident 37 if it was not taken as specified by manufacturer," LVN 3 told inspectors after they observed the error.
The same nurse delayed another resident's Vitamin D3 supplement for two hours because the physician ordered capsules but the facility only had tablets in stock. The nurse needed to clarify the order before administering the different formulation, but this delay violated the facility's policy requiring medications be given within 60 minutes of scheduled time.
Basic daily care also suffered. Resident 29, who has Alzheimer's disease and needs assistance with personal care, had a sign on his wall instructing staff to "remove lower dentures and disinfect with tablets at night." But Certified Nursing Assistant 4 told inspectors the resident had no denture cup or cleaning tablets at his bedside.
The resident's family member complained about oral care issues and dentures not being cleaned properly or placed in denture cups. A Licensed Vocational Nurse confirmed Resident 29 should have had a denture container at his bedside but didn't. She said the facility had run out of denture cleaning tablets.
The Registered Nurse Supervisor admitted she failed to check if Resident 29's dentures were being cleaned properly. The facility's own policy required storing dentures in containers with cleaning solution whenever they weren't in the resident's mouth, but staff weren't following these procedures.
Staffing information posted for residents and families contained inaccuracies. The Director of Staff Development acknowledged that daily sign-in sheets didn't match posted staffing levels due to call-offs that weren't reflected in public postings. She agreed the discrepancies should be corrected, noting that "quality of care suffers without accurate posted staffing."
Perhaps most concerning, the facility administered unnecessary psychotropic medication to Resident 22. The resident received Seroquel (quetiapine) daily for over a month despite having no psychiatric diagnosis documented in her assessment. The medication was initially ordered for "delirium" then changed to "schizophrenia manifested by hallucinations," but the resident's Minimum Data Set showed no psychiatric or mood disorders.
The consultant pharmacist conducting monthly medication reviews failed to identify this irregularity. The Quality Assurance Licensed Vocational Nurse acknowledged Resident 22 shouldn't receive quetiapine without a corresponding diagnosis, calling it "an unnecessary drug" that placed her at risk for altered mental status, respiratory distress, dizziness, vomiting, and low blood pressure.
Hospital records from the resident's admission showed "no anxiety, depression, or insomnia" in the psychiatric review. Yet the facility continued administering the antipsychotic medication based on family consent rather than medical necessity.
The facility's own policies required medications be given only when "clinically indicated to treat a specific condition" that is "diagnosed and documented in the medical record." But Resident 22's case showed a gap between written policies and actual practice that potentially compromised her mental and physical well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Seacrest Post-acute Care Center from 2025-02-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SEACREST POST-ACUTE CARE CENTER in SAN PEDRO, CA was cited for violations during a health inspection on February 28, 2025.
Staff left IV catheters in residents for weeks after treatment ended, administered medications incorrectly, and failed to provide proper denture care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.